Provider Demographics
NPI:1992078596
Name:THOMSON, JACK VINCENT II
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:VINCENT
Last Name:THOMSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 OAK LANE
Mailing Address - Street 2:
Mailing Address - City:DUNVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541
Mailing Address - Country:US
Mailing Address - Phone:434-822-0027
Mailing Address - Fax:
Practice Address - Street 1:130 WATSON ST
Practice Address - Street 2:WALGREENS
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541
Practice Address - Country:US
Practice Address - Phone:434-793-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist